ConnectedCare 2017: How hanges to lue ross’ QHP Individual ... · ConnectedCare 2017: How hanges to lue ross’ QHP Individual and Family Plans will impact Providers and Members.
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Hospital: Bear Lake Memorial Hospital, Caribou Memorial Hospital, Franklin County Medical Center, Lost Rivers Hospital, Madison Memorial Hospital, Minidoka Memorial Hospital, Nell J. Redfield Memorial Hospital, Power County Hospital District, Steele Memorial Hospital, Teton Valley Health Care
• Blue Cross of Idaho will actively engage with PQA Network enrollees to prompt them to choose a Primary Care Provider (PCP)
• Phone calls
• Emails
• Direct mail
• Co-branded mail from Blue Cross and PQA
• We’ll partner with PCPs during January 2017 to try and reach out to those who haven’t selected a PCP.
• PCPs need to keep Blue Cross informed of their patient loads and notify us immediately by email notification to the Provider Relations rep when their panel is closed
Members with tailored networks who receive care from an out-of-network provider during the initial transition period may have that care apply to their in-network benefits in the following scenarios:
• Continuation of care through the current period of active treatment (as defined below), or for up to 90 days, whichever is less.
• Continuation of care through the postpartum period (6 weeks) for members in their second or third trimester of pregnancy.
Following the initial transition period, in order to receive in-network benefits for that care, members must:
• Transition care to an in-network provider OR
• Obtain a gap-in-network authorization
Active Treatment: A member is undergoing an active course of treatment if the member has regular visits with the provider to monitor the status of an illness or disorder, provide direct treatment, prescribe medication, or other treatment to modify a treatment protocol. Active treatment does not include routine monitoring of a chronic condition.
• Specialists will need to enter the referring PCP into Box 17 and NPI in Box 17b, or the respective field in an electronic submission of the submitted claim form.
• Out-of-Area services and providers will require a referral from the PCP.
• Providers will undergo a periodic audit by PQA and Blue Cross to ensure they are actively supporting the coordinated care approach.
• Home health, home IV, hospice • Independent lab tests • Optometry • Pathology • PT/OT/ST • Radiology/Imaging services
(mammograms, x-rays, ultrasounds, MRIs, CT scans, PET scans) *NOTE - professional or interventional radiology services may be subject to referrals as specialists
• Registered dieticians • Psychotherapy
• Visits or services by primary care providers or generalists; primary care specialties include the following:
• Family practice • General practice • Internal medicine • OB/GYN • Pediatricians
• Anesthesia • Chiropractic • DME suppliers • Emergency or urgent care services
• Subscribers enrolling in a Qualified Health Plan must meet Blue Cross of Idaho’s residency requirements as outlined in the member contract.
• Idaho Residents Who Reside Outside their Tailored Network Service Area for Part of the Year
• In order for out-of-area services to apply to an in-network benefit, gap-in-network referrals are required, and subject to BCI approval as outlined in the Gap-in-Network Authorization Criteria. The requirement to seek care within the tailored network may be waived if it is not geographically feasible to receive services within the tailored network for a portion of the year, and services cannot be postponed until the member returns to the service area.
• Dependents Who Reside Outside of the Network Service Area
• Eligible dependents of a primary subscriber (also known as a policyholder or enrollee) may reside outside the service area, for example to attend school. In such cases, it is the responsibility of the primary subscriber to contact customer service to provide this information. Out-of-area services may be authorized at the in-network benefit level for these dependents, subject to BCI review of:
• Confirmation of the dependent’s out-of-state residency
• Requested services or procedures
• Providers are contracting in a Blue Cross of Idaho tailored network or the BCBSA BlueCard network.
Gap-in-network Authorization Criteria 1. Referral received from member’s PCP 2. Requested service is Covered and Medically Necessary 3. Requested service is not available within the member’s tailored network and,
a) Documentation of such provided by PCP and, b) When requested, documentation by an in-network specialist verifies the
requested specialized services cannot be provided within the member’s tailored network.
4. Referral is to a provider/facility: a) Within another BCI-contracting QHP tailored network* or, b) When (a) is not available, provider/facility is contracting in the standard BCI
network* or, c) When (a) and (b) are not available, referral is to a provider/facility contracting
with another Blue Cross Blue Shield plan (i.e., “BlueCard” network) *Or within a county contiguous to Idaho when the member is geographically remote (defined as 30 miles or more) from an alternate BCI-contracting provider, AND the specialty provider is geographically closer to the member than the BCI-contracting provider.
• Blue Cross of Idaho CEO Charlene Maher recently conducted an exclusive one-on-one interview with The Associated Press, focusing on the benefits of coordinated care and the QHP healthcare networks
• Media coverage is anticipated around the following dates:
• Anonymous shopping for plans (with rates) began Oct. 1
• Open enrollment period runs Nov. 1 through Jan. 31
• In May 2014, CMS implemented new rules surrounding the discontinued use of the Advanced Beneficiary Notice (ABN) and the use of ABN modifiers for Medicare Advantage Plans
• Providers are required to obtain an Organizational Determination from the Plan so that Members are notified by the Plan of any non-covered services
• Any services billed with an ABN modifier will be processed based on the following guidelines:
Services that are non-covered as an exclusion of the member EOC or statutory exclusion by CMS, will be processed to deny as member liability
Services that are not identified as a non-covered exclusion of the Member EOC or statutorily non-covered by CMS, will be denied as provider liability unless an organizational determination is obtained prior to services being rendered. If an organizational determination is on file for a service and determined to be non-covered, claim will process the denial as member liability.
Blue Cross of Idaho is committed to offering our providers tools and resources to help optimize patient health outcomes. This is consistent with CMS and/or NCQA audits, as well as various other initiatives and programs.
Please contact your area Provider Engagement Specialist to learn more about available tools and resources related to:
• Risk Score/HCC documentation and coding
• Risk Adjustment Data Validation Audits – for both Medicare Advantage and Qualified Health Plans
• Healthcare Quality Patient Assessment Form programs